中国新型农村合作医疗制度浅析.docx

中国新型农村合作医疗制度浅析摘 要：现行经济条件下，我国农村地区缺乏有效的社会保障，因病致贫、因病返贫现象十分突出。这些问题的存在，影响了农民健康状况的改善，也影响了农村经济社会的长期稳定发展。2003年起我国开始实行新型农村合作医疗制度，多年来改善了农民看病贫困的问题。但是，该项制度在实行过程中仍然存在一些问题，这是不容忽视的。本文则从四个方面简析了新农合面临的问题，希望能对问题的日后解决有所帮助。 关键词：基础 道德风险 逆向选择 资金筹集 法律法规 以大病统筹为主的农民医疗互助共济制度。主要是解决农民看病穷、没钱看病的问题。该合作医疗基金主要用来补偿参保农民的金额较大的医疗费用或者住院费用。新型农村合作医疗是我国政府第一次参与的合作医疗制度，表明我国社会政策向从城市向农村的倾斜。新农合自2003在我国局部地区试点以来，在政府的支持和推动下发展迅速，并在一定程度上缓解了农民看病费用问题。作为一项关系着广大农民健康的惠民政策，新型农村合作医疗还面临着一些问题，需要我们去探讨去解决。 （一）基础不扎实 我国新型农村合作医疗制度以保大为主，俗称“保大不保小”，把主要精力放在“大病统筹”方面。有人认为，新型农村合作医疗制度“保障目标定为保大病，事实上放弃了对大多数人基本医疗需求的保障责任”，农村缺医少药，这种现象自新农合开始试点以来并没有得到根本性的改善。很多实行新农合的地方，依然有农民生病了拖着，导致最终拖成严重的疾病。在”保大不保小”制度下，很多农民会报销医药费，小病也去住院，小病按照花费大的方向去治疗，这也导致了医疗资源的浪费。在广大发达地区，新农合的根本性障碍不是经济问题，而在广大中西部地区，经济问题却成为新农合发展的首要问题在对河南省汝州市温泉乡侧崆庄的调查中发现，2006 年，该社区（村）总人口1080人，参保708人，未参加372人，参合率为65.55%, ，低于全国2004年10月统计的72.6%, 的平均参合率及汝州市81.9%的参合率。在未参合的农民中，除在外打工和年轻者不愿参加外，其余的12 户人家均属经济问题。郏县堂街镇退保的农民中67% 归因于经济原因。这表明新农合的拓宽基础的工作并没有有效地落实。 （二）“道德风险”和“逆向选择”问题突出 新农合的实施过程中存在着道德风险问题。主要表现在：一些医生为获取回扣，则常常通过多开些药甚至开贵的药给患者，这给农民消费了成本过高的医药，增加了其肩上的医疗负担，也造成医药资源的浪费。还有一些定点医院为追逐过多的利润，提高医疗服务的收费，服务和医药的高价格也抵消了新农合给农民带来的优惠，农民的利益遭受到损害。逆向选择的问题主要表现在：往往是风险高的患者比风险低的患者更愿意参加医疗保险。一些容易生病或者身体状况很不佳的人群往往更倾向于参加新型农村合作医疗，而身体健康的人群参与的积极性却不高。同时，对参保农民的费用控制目前也缺乏一些有效的方法，很多时候出现小病大看，无病骗保现象。这些逆向选择一旦产生，将对新农合的可持续发展产生很不利的影响。 （三）筹资难度大 资金筹集对于我国新型农村合作医疗保险来说是十分重要的，是保证其持续顺畅运行的基础。就目前的情况来看，新农合资金的筹集在总体上看到位情况是不错的，达到90%。揭开高到位率的面纱，隐含筹资的可持续性问题又会浮现出来。 新农合实施过程中，有部分农民虽有能力但却没有缴费参加保险，这可能由于新农合实施的年限不长，农民对于它的前景还没有足够的看清楚，同时农民对于很多干部及政策也存在着不大信任的因素。新农合已经筹到的资金，好多是基础执行人员上门收取，甚至采取谈判的形式来筹集，还有一部分甚至采取强制性的措施。这样筹资方式只能保证一时能筹集到所要的资金，但对可预见的未来能否持续筹集到稳定的资金并不能起保证作用。 政策规定的筹集资金程序是一层一层来的，中央补助资金是要在地方政府补助资金到位后拨付，地方补助资金是在农民交费后再拨付。而由于农民对地方政府存在着不大信任的因素，很多时候不愿意先交钱，担心地方政府收费不透明，这样筹集资金就不大顺利。一些基层干部为完成规定指标以追求政绩，强迫农民参加新农合，还强迫一些卫生院和乡村医生代收费用。再者，基层出现财政紧张时无法兑现对农民的资金补助，从而导致中央和上级财政拨款未能按时到位。 （四）法律法规不健全 新农合制度从试点到实行已经有几年时间，但是目前国家还没有将其纳入强制实施的法律范畴。国家有出台国务院关于建立新型农村合作医疗制度的指导意见，但是还没有一些具体的法律法规来指导新农合的实践，使得人们对新农合的认识并不能达到统一。很多地方采取签订责任书的形式以期加大基层干部参与合作医疗的责任心和统一他们的思想，但是这些措施随意性较大，也容易受到各种因素的干扰。同时，农民、医疗机构和政府和商业机构之间四方并没有建立起合同关系，农民在权益受到损害时往往申诉无果，大大削弱了农民参加新农合的积极性。政府、商业保险机构和惨加保险的农民三者之间的法律关系并不明确，商业保险在与政府签订委托协议时，与参加保险的农民之间也存在着某种程度上的关系。这样，这三者之间的权利义务关系便不能合理确定，这增加了商业保险机构参加新农合过程中的风险。再者，由于缺乏配套的政策制度和法律法规，对于保险公司、政府和政府主管机构之间权利、义务和责任无法区分清楚，这也大大影响到保险公司参与保险的积极性。 参考文献： 1刘军民.农村合作医疗存在的制度缺陷N.华中师范大学学报.2006,(3):37-41. 2王芹萼.新型农村合作医疗的可持续发展支持探讨J.消费导刊,2008(2):38-39. 3韩留富.试论新型农村合作医疗制度可持续发展的对策J.北方经济,2006,(2):11-12.References1X. Feng, S. Tang, G. Bloom, M. Segall, X. GuCooperative medical schemes in contemporary rural ChinaSocial Science and Medicine, 41 (1995), pp. 111111182W. HsiaoTransformation of health care in ChinaNew England Journal of Medicine, 310 (1984), pp. 932936View Record in Scopus| Full Text via CrossRef| Citing articles (56)3X. Gu, G. Bloom, S. Tang, Y. Zhu, S. Zhou, X. ChenFinancing health care in rural China: preliminary report of a nationwide studySocial Science and Medicine, 36 (1993), pp. 3853914X.M. Chen, D.W. Hu, Z.H. LinThe rise and decline of the cooperative medical system in rural ChinaInternational Journal of Health Service, 23 (1993), pp. 731742View Record in Scopus| Full Text via CrossRef| Citing articles (14)5G. Carrin, A. Ron, Y. Hui, W. Hong, Z. Tuohong, Z. Licheng, et al.The reform of the rural cooperative medical system in the Peoples Republic of China: interim experience in 14 pilot countiesSocial Science and Medicine, 48 (1999), pp. 961972Article| PDF (132 K)| View Record in Scopus| Citing articles (54)6S. TangThe changing role of the township health centers in the context of economic reform in ChinaIDS Bulletin, 28 (1997), pp. 3947View Record in Scopus| Citing articles (9)7S. Jackson, A.C. Sleigh, P. Li, X. LiuHealth finance in rural Henan: low premium insurance compared to the out-of-pocket systemThe China Quarterly, 181 (2005), pp. 137157View Record in Scopus| Full Text via CrossRef| Citing articles (12)8K. Liu, W. FanThe analysis on fluctuation of cooperative medical scheme of two counties in Shanxi province in 1990sChinese Health Economics, 21 (2002), pp. 1417 (in Chinese)9Hsiao W. Plenary Session. Chinese Economists Society Annual Conference, Chongqing, 2005 June 24.10M. Lindelow, A. WagstaffHealth shocks in China: are the poor and uninsured less protected? World BandPolicy Research Working Paper (2005), p. 374011A. WagstaffThe economic consequence of health shocksWorld Bank, Policy Research Working Paper (2005), p. 364412B. Gustafsson, S. LiExpenditures on Education and health care and poverty in rural ChinaChina Economic Review, 15 (2003), pp. 29230113Ministry of Health (PRC). Research on national health services: an analysis report of the second national health service survey in 1998. Beijing; 1999 (in Chinese).14Y. Liu, K. Rao, W. HsiaoMedical expenditure and rural impoverishment in ChinaJournal of Health Population Nutrition, 21 (2003), pp. 216222View Record in Scopus| Citing articles (90)15M. Liu, Q. Zhang, M. Lu, C.S. Kwon, H. QuanRural and urban disparity in health services utilization in ChinaMedical Care, 45 (2007), pp. 767774View Record in Scopus| Full Text via CrossRef| Citing articles (38)16X. Zhang, R. KanburSpatial inequality in education and health care in ChinaChina Economic Review, 16 (2005), pp. 189204Article| PDF (138 K)| View Record in Scopus| Citing articles (102)17Akin JS, Dow WH, Lance PM, L CA. Changes in access to health care in China, 19891997. Health Policy 2005;20:809.18J. Gao, J. Qian, S. Tang, B. Eriksson, E. BlasHealth equity in transition from planned to market economy in ChinaHealth Policy and Planning, 17 (2002), pp. 2029View Record in Scopus| Full Text via CrossRef| Citing articles (69)19H.B. YinThe National Rural Health Conference was convened in BeijingPeoples Daily (2002 October 29)20Y. WangDevelopment of the new rural cooperative medical system in ChinaChina & World Economy, 15 (4) (2007), pp. 6677View Record in Scopus| Full Text via CrossRef| Citing articles (14)21Y. LiuDevelopment of the rural health insurance system in ChinaHealth Policy and Planning, 19 (2004), pp. 15916522S. BennettThe role of community-based health insurance within the health care financing system: a framework for analysisHealth Policy and Planning, 19 (2004), pp. 14715823World Health Organization. Health systems: improving performance. The World Health Report 2000. Geneva: WHO; 2000.24G. Carrin, M. Waelkens, B. CrielCommunity-based health insurance in developing countries: a study of its contribution to the performance of health financing systemsTropical Medicine and International Health, 10 (2005), pp. 79981125Y. Liu, K. RaoProviding health insurance in rural China: from research to policyJournal of Health Politics, Policy and Law, 31 (2006), pp. 719126Ministry of Health (PRC). Notification of accelerating the progress of New Cooperative Medical Scheme. Beijing. 2006 (in Chinese).27J. WattsChinas rural health reforms tackle entrenched inequalitiesThe Lancet, 367 (2006), pp. 1564156528Xinhua News. China to increase subsidies for rural medical scheme, January 7, 2008.29Mao Z. Pilot program of Chinas new cooperative medical scheme system design and progress. United Nations for Economic and Social Commission for Asian and the Pacific. http:/www.unescap.org/esid/hds/issues/index.asp; 2006.30L. Zhang, H. Wang, L. Wang, W. HsiaoSocial capital and farmers willingness-to-join a newly established community-based health insurance in rural ChinaHealth Policy, 76 (2006), pp. 23324231Ministry of Health (PRC). National statistical yearbook on the new cooperative medical scheme. Beijing; 2006 (in Chinese).32Xinlang News. Progress made at NCMS. September 5, 2007 (in Chinese).33Ministry of Health (PRC). National statistical yearbook on the new cooperative medical scheme. Beijing; 2004 (in Chinese).34Ministry of Health (PRC). National statistical yearbook on the new cooperative medical scheme. Beijing; 2005 (in Chinese).35Wu M, Zhang Z, He M, Ruan Y, Lv C, Tao L, Miao M. Qualitative study on the implementation and determinants of the new cooperative medical system in rural China. Study report from WB/MOH NCMS study; 2006.36Brown PH, de Brauw A. Chinas new cooperative medical system: variation and prospects. Paper presented at the Chinese Economists Society Annual Meeting, June 24, 2005.37J. ParryChina wants to make health care more affordable to poorBMJ, 336 (2008), p. 57838M. GaoReflection on sustainability of New Cooperative Medical Scheme from demandHealth Economics Research, 10 (2004), pp. 36 in Chinese39H. Wang, W. Yip, L. Zhang, L. Wang, W. HsiaoCommunity-based health insurance in poor rural China: the distribution of net benefitsHealth Policy and Planning, 20 (2005), pp. 36637440H. Wang, L. Zhang, W. Yip, W. HsiaoAdverse selection in a voluntary Rural Mutual Health Care health insurance scheme in ChinaSocial Science and Medicine, 63 (2006), pp. 1236124541A. Wagstaff, M. Lindelow, J. Gao, L. Xu, J. QianExtending health insurance to the rural population: an impact evaluation of Chinas New Cooperative Medical SchemeWorld Bank Policy Research Working Paper (2007), p. 415042J. Liu, L. Xu, X. Cao, X. Wang, H. Sun, C. Tang, Z. Yang, X. Song, M. LvAnalysis of satisfaction about new cooperative medical scheme and its influencing factors in Weihai, ChinaHealth Policy, 86 (2008), pp. 23924443H. Wang, D. Gu, M.E. DupreFactors associated with enrollment, satisfaction, and sustainability of the New Cooperative Medical Scheme program in six study areas in rural BeijingHealth Policy, 85 (2008), pp. 324444NCMS Pilots Evaluation Team. Evaluation reports on Chinas new cooperative medical scheme. Beijing: Peoples Medical Publishing House; 2006 (in Chinese).45Q. ZuoAn empirical analysis of Rural Mutual Health Care: on the basis of investigation study of experimental units in Guizhou, Inner Mongolia and ShanxiHebei Law Science, 24 (2006), pp. 139142 (in Chinese)46Brown PH, de Brauw A, Yang D. The New cooperative Medical System: does it help farmers with health shocks maintain living standards? (English summary) China Labor Economics; 2007.47Ministry of Health (PRC). Reports on the 2003 national health services survey results. Beijing; 2004 (in Chinese).48State Council (PRC). Wu Yi emphasized: constantly reinforce and improve New Cooperative Medical Scheme. Beijing. 2008 (in Chinese).49X. Zheng, S. HillierThe reforms of the Chinese health care system: county level changes: the Jiangxi studySocial Science and Medicine, 41 (1995), pp. 1057106450X. Gu, S. TangReform of the Chinese health care financing systemHealth Policy, 32 (1995), pp. 18119151G. Bloom, X.Y. GuHealth sector reform: lessons from ChinaSocial Science and Medicine, 45 (1997), pp. 35136052Q. Meng, X. Liu, J. ShiComparing the services and quality of private and public clinics in rural ChinaHealth Policy and Planning, 15 (2000), pp. 34935653Ministry of Health (PRC). Research report on China national health accounts. Beijing; 2004 (in Chinese).54X. Sun, A. Sleigh, D. Han, A. ZhangManaged care in the United States and its implications to new rural cooperative medical care in ChinaHealth Economics Research, 8 (2005), pp. 3335 (in Chinese)55S. Zhan, S. Tang, Y. Guo, G. BloomDrug prescribing in rural health facilities in China: implications for service quality and costTropical Doctor, 28 (1997), pp. 424856L. Dong, H. Yan, D. WangAntibiotic prescribing patterns in village health clinics across 10 provinces of western ChinaJournal of Antimicrobial Chemotherapy (2008) (Published online on April 9)57Bank. WorldTaking stock of Chinas rural health challengeThe World Bank, Washington, DC (2004)58D. Blumenthal, W. HsiaoPrivatization and its discontents: the evolving Chinese health care systemNew England Journal of Medicine, 353 (2005), pp. 1165117059X. Liu, A. MillsEvaluating payment mechanisms: how can we measure unnecessary care?Health policy and Planning, 14 (1999), pp. 40941360Sun X, Jackson S, Carmichael G, Sleigh AC. Effects of the New Cooperative Medical Scheme on village doctors prescribing behavior in Shandong Province. Discussion Papers Series 354, School of Economics, University of Queensland, Australia. http:/www.uq.edu.au/economics/abstract/354.pdf; 2008.61H. WangImpacts of medicine price on New Cooperative Medical SchemeChina Price, 11 (2005), pp. 2324 in Chinese62W. Yip, W.C. HsiaoThe Chinese health system at a crossroadsHealth Affairs, 27 (2008), pp. 46046863A. Wagstaff, M. LindelowCan insurance increase financial risk? The curious case of health insurance in ChinaJournal of Health Economics, 27 (2008), pp. 990100564S. HuOverview of NCMS models in ChinaChinese Journal of Primary Health Care (9) (2003), pp. 16 in Chinese65G. Wang, H. Xu, M. JiangEvaluation on comprehensive quality of 456 doctors in township hospitalsJournal of Health Research (6) (2003), pp. 7274 (in Chinese)66Meng Q. Review of provider organization reforms in China. China Rural Health AAA Background Report 2005.67K. Eggleston, L. Li, Q. Meng, M. Lindelow, A. WagstaffHealth service delivery in China: a literature reviewHealth Economics, 17 (2008), pp. 14916568Sun X, Jackson S, Carmichael G, Sleigh AC. Catastrophic medical payment and financial protection in rural China: evidence from the New Cooperative Medical Scheme in Shandong province. Health Economics. Published online in Wiley InterScience (). doi:10.1002/hec.1346; 2008.References1X. Feng, S. Tang, G. Bloom, M. Segall, X. GuCooperative medical schemes in contemporary rural ChinaSocial Science and Medicine, 41 (1995), pp. 111111182W. HsiaoTransformation of health care in ChinaNew England Journal of Medicine, 310 (1984), pp. 932936View Record in Scopus| Full Text via CrossRef| Citing articles (56)3X. Gu, G. Bloom, S. Tang, Y. Zhu, S